=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780089763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY ACUPUNCTURE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2014
-----------------------------------------------------
Last Update Date | 11/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 437 69TH ST
-----------------------------------------------------
City | GUTTENBERG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07093-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-868-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 437 69TH ST
-----------------------------------------------------
City | GUTTENBERG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07093-2413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-868-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | YOUNG K LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-868-4400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | 25MZ00048200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------